Dáil Éireann - Volume 471 - 12 November, 1996
Adjournment Debate. - Administration of Wrong Vaccine.
Mr. Power Mr. Power
Mr. Power: I wish to share my time with Deputy Moffatt.
An Ceann Comhairle Seán Treacy
An Ceann Comhairle: That is satisfactory.
Mr. Power Mr. Power
Mr. Power: Last Wednesday, 5 November, 66 children at St. Conleth's school in Newbridge were inadvertently given a three-in-one vaccination rather than a two-in-one vaccination. This error caused much concern when it was noted and Eastern Health Board doctors visited parents the following day to explain what had happened and to examine the children. The Eastern Health Board realised the seriousness of its mistake and acted in a mature and reassuring way.
This controversy raises many serious issues. These include how the wrong vaccine was in the possession of the doctor, the absence of the written consent of parents for their children to be given a whooping cough vaccine and the attention paid to the medical history of the children before the administration of the vaccine.
It is vital that the Minister for Health takes immediate action to reassure the public about the health services and to ensure that a similar controversy does not arise anywhere else. The chief executive officer of the Eastern Health Board has appointed an independent external group to investigate the circumstances leading up to and surrounding this controversy and to review Protocols to ensure a similar incident does not occur. Will the Minister ensure the findings of the investigation are made public? This is the least the parents of these children deserve.
Dr. Moffatt Dr. Moffatt
Dr. Moffatt: I thank Deputy Power for sharing his time with me. This controversy which involves the administration of the wrong vaccine to 66 school children in Newbridge comes on top of the hepatitis C scandal. There is, therefore, an urgent need for the Minister for Health to take  immediate steps to reassure the public about the health services and to put in place proper procedures on the administration of vaccines.
This controversy raises a number of serious questions. For example, why did the people who administered the vaccine have a three-in-one vaccine with them? It is important for the inquiry to be held speedily and for the Minister to give a commitment to publish the facts. It is also imperative that he puts in place new procedures on the administration of vaccines. These should include the use of best practice and attendance by parents at schools on the day of vaccination. The inquiry should cover issues such as the state of the child's health before the vaccination, his or her vaccination history and ongoing neurological problems. It is important for the written consent of parents to be given for the administration of vaccines to children.
The uptake of vaccines is not great at present and it is very important for the Minister to do everything in his power to ensure that the proper procedures are put in place. This will reassure parents that their children are receiving the proper vaccinations, that the best system is in place and that the newest vaccines are administered. This is very important in terms of the new three-in-one vaccination.
It is important for a doctor and nurse to be present during the administration of the vaccine. Vaccines should be colour coded while the label should include information on the type of vaccine, the date of manufacture and the date of expiry. This would help to eliminate many of the present problems. Vaccines should ideally be administered in surgeries so that doctors have the necessary equipment to deal with any allergic reactions. It is very important for proper procedures to be put in place to reassure the public about the safety of vaccinations.
Minister of State at the Department of Health (Mr. O'Shea) Minister of State at the Department of Health (Mr. O'Shea)
Minister of State at the Department of Health (Mr. O'Shea): I thank Deputies Power and Moffatt for raising this matter. The facts surrounding this incident were set out clearly by the Eastern Health Board in a press release issued last Friday. Before summarising these, I want to make it absolutely clear that the board acknowledged from the outset that a serious mistake was made in the administration of the vaccine in question. Fortunately, no child appears to have suffered any adverse consequence and the most important issue, therefore, is to find out exactly how the mistake was made and to put in place the necessary safeguards to ensure it will not happen again.
The children concerned were supposed to receive a routine two-in-one vaccine which provides immunisation against diphtheria and tetanus. This is a booster for the immunisation children receive when they are babies, at which stage they normally receive a three-in-one vaccine which includes immunisation against pertussis, commonly known as whooping cough. The pertussis part of the vaccine is not offered  in the school booster programme as the risk of contracting this disease is very much less by the time children reach school going age. This does not imply that the vaccine is contra-indicated for that age group; it is given to school children aged between four and six years in the United States.
The wrong vaccine, that is the three-in-one rather than the two-in-one, was administered in this case. As soon as the doctor concerned realised what had happened the health board was informed and arrangements were immediately put in place to inform the parents and to check on the children. In addition to visiting all the families, a 24 hour freephone, manned by doctors, was set up for parents who were concerned about their children. I am informed that apart from the normal minor, temporary reactions which occur as much with the two-in-one vaccination as with the three-in-one vaccination there have been no adverse reactions by the children.
The Eastern Health Board has appointed an independent external group to investigate the circumstances leading up to and surrounding this mistake and to review Protocols to ensure that it will not happen again. The Minister for Health has asked the board to ensure this investigation is carried out as quickly as possible, and I understand it is likely to be completed next week.
The House will appreciate that we cannot reach a final judgment on the circumstances in this case until the investigation has been completed. There is no question but that a serious mistake was made. However, the health board acted promptly and comprehensively on two fronts: first, by providing the necessary reassurance to parents and checking their children and, second, by setting up the investigation to which I referred. It also provided full and detailed information to the media, which has helped to avoid any unnecessary panic. The Minister will look carefully at the report of the investigation and any necessary action, whether in the Eastern Health Board or in health boards generally, will be taken.
Mr. Power Mr. Power
Mr. Power: Will the report be made public?
Mr. Allen Mr. Allen
Mr. Allen: I will raise that matter with the Minister.
Dáil Éireann 471 Adjournment Debate. Administration of Wrong Vaccine.